To: Social Security Administration Re: ______(Name of Patient) s2

To: Social Security Administration Re: ______(Name of Patient)

______(Social Security No.)

Please comment on whether your patient has the following impairment: Disorders of the spine (e.g., herniated nucleus pulposus, spinal arachnoiditis, spinal stenosis, osteoarthritis, degenerative disc disease, facet arthritis, vertebral fracture), resulting in compromise of a nerve root (including the caudal equina) or the spinal cord. With: A. Evidence of nerve root compression characterized by neuro-anatomic distribution of pain, limitation of motion of the spine, motor loss (atrophy with associated muscle weakness or muscle weakness) accompanied by sensory or reflex loss and, if there is involvement of the lower back, positive straight-leg raising test (sitting and supine).

1. Does your patient have a disorder of the spine? ___Yes ___No

If yes, please identify the disorder: ______

2. Does your patient have evidence of nerve root compression? ___Yes ___No

3. Does your patient have neuro-anatomic distribution of pain? ___Yes ___No

If yes, please describe: ______

4. Does your patient have any limitation of motion of the spine? ___Yes ___No

If yes, indicate range of motion with the following movements:

Flexion ° Lateral bending - right °

Extension ° Lateral bending – left °

Other: ______

5. Does your patient have any muscle weakness? ___Yes ___No

If yes, please identify the affected muscles and describe using the grading system 0 to 5: ______

Identify any positive signs of motor loss:

___ Inability to walk on heels ___ Inability to squat

___ Inability to walk on toes ___ Inability to arise from squatting position

___ Atrophy: Please indicate circumferential measurements of both thighs and lower legs or upper and lower arms as appropriate:______

6. Does your patient have sensory or reflex loss? ___Yes ___No

If yes, please describe:______

______

7. Is there involvement of the lower back? ___Yes ___No

If yes, does your patient have a positive straight-leg raising test both sitting and supine? ___Yes ___No

Please describe: ______

______

8. If the clinical findings do not match all of the findings required above, are your patient's combined impairments medically equivalent to the severity of conditions in the above listed impairment?

___Yes ___No

If yes, please explain in detail how your patient's impairments are equivalent to the impairment listed above, with reference to specific supporting clinical findings. ______

______

9. What is the earliest date that the description of symptoms and limitations in this form applies? ______

Physician’s Signature: ______

Date form completed: ______

Printed/Typed Name: ______

Address: ______

______Return form to:

Mike Murburg, PA

15501 N. Florida Ave

Tampa, FL 33613

Tel: 813-264-5363

Fax: 814-814-9788